Health Information Form

Camper Health Information Form

* Indicates required field

Camper Full Name *

First

Last

Home Address - Street # & Name *

Home Address - City *

Home Address - Province/State *

Home Address - Postal/Zip Code *

Home Phone Number *

Email *

Gender *

Female Male

Last Grade Completed *

School Name *

1st Parent/Guardian Full Name *

1st Parent/Guardian Phone Number *

1st Parent/Guardian Email *

2nd Parent/Guardian Full Name *

2nd Parent/Guardian Phone Number *

2nd Parent/Guardian Email *

Parents' Marital Status *

Married Separated Divorced

Visitation Rights & Custody Information (if applicable) *

Upload Custody Documents (if applicable) *

Max file size: 20MB

Emergency Contact Name, Relation *

Emergency Contact Phone Number *

Does your child have any PHYSICAL or SENSORY facility needs? *

Please list all of your child's ALLERGIES (complete Allergy Form as well) *

Please list all of your child's PREVIOUS OPERATIONS or SERIOUS INJURIES *

Please list any chronic or recurring ILLNESSES or MEDICAL CONDITIONS *

Please list all MEDICATIONS your child is current taking (and send us instructions) *

Please list your child's DIETARY RESTRICTIONS *

Family Physician Name and Phone Number *

Dentist Name and Phone Number *

OHIP # (for Ontario residents only) *

Health Insurance Policy Number & Carrier *

Travel Insurance (for International Campers only) *

Cabin request *

Other Important Information about your child *

How did you hear about Camp Eden Woods? *

I authorize Camp Eden Woods to charge my credit card up to $50 for any necessary purchases for my child. (ie.tooth paste, soap, sunscreen etc….) *

Agree Disagree

SUBMIT BUTTON IS BELOW CONDITIONS

Conditions: Camp Eden Camps will not accept responsibility for any money lost or stolen. Similarly, Camp Eden Camps will not be held responsible for any damage, loss or that of any campers personal belongings. Campers are encouraged not to bring any valuables. Although Camp Eden Camps strives to maintain originally planned activities and schedules, each program is subject to change due to weather and/or other special circumstances. Medication carried by campers will not be administered if contents and instructions are not properly labeled by a pharmacist or a physician. It is the responsibility of the parent/guardian to inform Camp Eden Camps if there are any changes in the child’s medical condition after this form has been submitted. If the camper has a presently life-threatening allergy or food sensitivity, we ask that the parent or guardian contact the office prior to completing and returning this form so that an allergy description form can be mailed to you. Please note that Camp Eden and Camp Eden Woods are nut-aware environments, but cannot guarantee being free of peanuts or other foods that may cause allergic reactions. Information collected on this form is for the use of the medical and programming decisions of Camp Eden Camps. We will not share personal information with any other organization, except for medical professionals, without the prior consent of the parents/guardians. For questions about our privacy policy, please contact our privacy coordinator, Sharon Gluzberg. Occasionally we give out our camp families’ names and phone numbers as references for other potential camp families. Please indicate whether you give consent for contact information to be given out for these purposes only. We do not give out contact information to any commercial agencies. Please Circle One: You may pass on my name to potential Camp Eden families Please do not pass on my name to anyone. Personal Declaration This personal and health history is correct so far as I know, and the person herein described has permission to engage in all camp activities except as noted. Authorization for treatment: I hereby give permission to the medical personnel selected by the camp director to order x-rays, routine tests, treatment, to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me or the child named above. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named above, as well as charge my credit card on file up to $100 if necessary. I agree to be responsible for any expenses incurred by my child or by Camp Eden or Camp Eden Woods on behalf of my child. This completed form may be photocopied for trips out of camp. I consent to Camp Eden using any photos taken of my child in its yearbook and promotional materials. By agreeing to these statements you are stating that you have read and agreed to all of them. *

Conditions Acceptance *

Agree Disagree

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Camper Health Information

Camper Health Information Form

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